1
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Kumar N, Palmisciano P, Dhawan S, Boakye M, Drazin D, Sharma M. Spontaneous Spinal Hematoma in Patients Using Antiplatelets and Anticoagulants: A Systematic Review. World Neurosurg 2024; 184:e185-e194. [PMID: 38278210 DOI: 10.1016/j.wneu.2024.01.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Spontaneous spinal hematoma (SSH) is a debilitating complication in patients taking either antiplatelet (AP) or anticoagulation (AC) medications. SSH is rare and, therefore, a systematic review is warranted to re-examine and outline trends, clinical characteristics, and outcomes associated with SSH formation. METHODS PubMed, EMBASE, Scopus, and Web-of-Science were searched. Studies reporting clinical data of patients with SSH using AC medications were included. In addition, clinical studies meeting our a priori inclusion criteria limited to SSH were further defined in quality through risk bias assessment. RESULTS We included 10 studies with 259 patients' pooled data post-screening 3083 abstracts. Within the cohort (n = 259), the prevalence of idiopathic, nontraumatic SSH with concomitant treatment with AC medications was greater 191 (73.75%) compared with AP treatment (27%). The lumbar spine was the most common site of hematoma (41.70%), followed by the cervical (22.01%) and thoracic (8.49%) spine. Most patients had surgical intervention (70.27%), and 29.73% had conservative management. The pooled data suggest that immediate diagnosis and intervention are the best prognostic factors in clinical outcomes. American Spinal Injury Association grading at initial symptom onset and post-treatment showed the greatest efficacy in symptomatic relief (87.64%) and return of motor and sensory symptoms (39.19%). CONCLUSIONS Our review suggested that AC medications were related to SSH in most patients (74%), followed by APs (27%) and combined ACs + APs (1.9%). We recommend prompt intervention, a high suspicion for patients with neurologic deficits and diagnostic imaging before intervention to determine a case-specific treatment plan.
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Affiliation(s)
- Nitesh Kumar
- Clinical Medicine, Windsor University School of Medicine, Chicago, Illinois, USA
| | - Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sanjay Dhawan
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Doniel Drazin
- Department of Neurosurgery, Providence Everett Neuroscience Center, Everett, Washington, USA
| | - Mayur Sharma
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.
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2
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Fournel J, Hermier M, Martin A, Gamondès D, Tommasino E, Broussolle T, Morgado A, Baassiri W, Cotton F, Berthezène Y, Bani-Sadr A. It Looks Like a Spinal Cord Tumor but It Is Not. Cancers (Basel) 2024; 16:1004. [PMID: 38473365 DOI: 10.3390/cancers16051004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 03/14/2024] Open
Abstract
Differentiating neoplastic from non-neoplastic spinal cord pathologies may be challenging due to overlapping clinical and radiological features. Spinal cord tumors, which comprise only 2-4% of central nervous system tumors, are rarer than non-tumoral myelopathies of inflammatory, vascular, or infectious origins. The risk of neurological deterioration and the high rate of false negatives or misdiagnoses associated with spinal cord biopsies require a cautious approach. Facing a spinal cord lesion, prioritizing more common non-surgical myelopathies in differential diagnoses is essential. A comprehensive radiological diagnostic approach is mandatory to identify spinal cord tumor mimics. The diagnostic process involves a multi-step approach: detecting lesions primarily using MRI techniques, precise localization of lesions, assessing lesion signal intensity characteristics, and searching for potentially associated anomalies at spinal cord and cerebral MRI. This review aims to delineate the radiological diagnostic approach for spinal cord lesions that may mimic tumors and briefly highlight the primary pathologies behind these lesions.
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Affiliation(s)
- Julien Fournel
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Marc Hermier
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Anna Martin
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Delphine Gamondès
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Emanuele Tommasino
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Théo Broussolle
- Department of Spine and Spinal Cord Neurosurgery, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Alexis Morgado
- Department of Spine and Spinal Cord Neurosurgery, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Wassim Baassiri
- Department of Spine and Spinal Cord Neurosurgery, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
| | - Francois Cotton
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, 7 Avenue Jean Capelle, 69100 Villeurbanne, France
- Department of Radiology, South Lyon Hospital, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495 Pierre-Bénite, France
| | - Yves Berthezène
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, 7 Avenue Jean Capelle, 69100 Villeurbanne, France
| | - Alexandre Bani-Sadr
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, 59 Bd Pinel, 69500 Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, 7 Avenue Jean Capelle, 69100 Villeurbanne, France
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3
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Jadhav AP. Vascular Myelopathies. Continuum (Minneap Minn) 2024; 30:160-179. [PMID: 38330477 DOI: 10.1212/con.0000000000001378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Vascular injuries of the spinal cord are less common than those involving the brain; however, they can be equally devastating. This article discusses the diagnosis and management of ischemic and hemorrhagic vascular disorders of the spinal cord. LATEST DEVELOPMENTS Clinical suspicion remains the mainstay for recognizing vascular myelopathies, yet diagnoses are often delayed and challenging in part because of their rarity and atypical manifestations. Noninvasive imaging such as CT and MRI continues to improve in spatial resolution and diagnostic precision; however, catheter-based spinal angiography remains the gold standard for defining the spinal angioarchitecture. In addition to hemorrhagic and ischemic disease, the contribution of venous dysfunction is increasingly appreciated and informs treatment strategies in conditions such as intracranial hypotension. ESSENTIAL POINTS Vascular disorders of the spine manifest in variable and often atypical ways, which may lead to delayed diagnosis. Increased awareness of these conditions is critical for early recognition and treatment. The goal of treatment is to minimize long-term morbidity and mortality.
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4
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Ando T. [The differential diagnosis of inflammatory and non-inflammatory myelopathy]. Rinsho Shinkeigaku 2023; 63:806-812. [PMID: 37989285 DOI: 10.5692/clinicalneurol.cn-001909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
The differential diagnosis of inflammatory and non-inflammatory myelopathy can be challenging. Clinical information such as age, gender, speed of onset and progression, systemic symptoms, spinal cord and brain MRI, autoantibodies, and cerebrospinal fluid findings are necessary. The speed of onset is particularly important for differentiation. Inflammatory myelopathy typically follows an acute/subacute course, while spinal cord infarction presents with a hyperacute course, and intramedullary tumors often have a chronic progressive course. Spinal dural arteriovenous fistula usually shows a chronic progressive course, but it can present with fluctuating symptoms in the early stages and may appear as an acute onset. It is essential to definitively exclude compressive myelopathy for the diagnosis of inflammatory myelopathy. Even if a definitive diagnosis cannot be made, regular reevaluation during treatment is necessary.
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Affiliation(s)
- Tetsuo Ando
- Department of Neurology, Kameda Medical Center
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5
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Padilha IG, Fonseca APA, Amancio CT, Vieira APF, Pacheco FT, da Rocha AJ. Vascular Myelopathies. Semin Ultrasound CT MR 2023; 44:408-423. [PMID: 37690793 DOI: 10.1053/j.sult.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
There are many vascular disorders that can affect the spinal cord, and their prevalence and etiology are highly influenced by age, sex, and risk factors. This article reviews the embryology and anatomy of the spinal cord, as well as several vascular conditions, describing their clinical and imaging presentation, emphasizing the different imaging modalities' contributions to increasing specificity and better defining the most appropriate therapy strategy for improving the patient's prognosis.
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Affiliation(s)
- Igor Gomes Padilha
- Division of Neuroradiology, Diagnósticos da América SA-DASA, São Paulo, SP, Brazil; Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil; Division of Neuroradiology, Unitedhealth Group, São Paulo, SP, Brazil.
| | - Ana Paula Alves Fonseca
- Division of Neuroradiology, Diagnósticos da América SA-DASA, São Paulo, SP, Brazil; Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil; Division of Neuroradiology, Unitedhealth Group, São Paulo, SP, Brazil
| | - Camila Trolez Amancio
- Division of Neuroradiology, Diagnósticos da América SA-DASA, São Paulo, SP, Brazil; Division of Neuroradiology, Hospital Sirio-Libanês, São Paulo, SP, Brazil
| | | | - Felipe Torres Pacheco
- Division of Neuroradiology, Diagnósticos da América SA-DASA, São Paulo, SP, Brazil; Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | - Antônio José da Rocha
- Division of Neuroradiology, Diagnósticos da América SA-DASA, São Paulo, SP, Brazil; Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
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6
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Das A, Vazquez S, Spirollari E, Dominguez J, Kinon MD, Houten JK. Intramedullary Spinal Hemorrhage in Behcet's Syndrome: A Case Report and Systematic Review. Cureus 2023; 15:e47134. [PMID: 38022098 PMCID: PMC10650936 DOI: 10.7759/cureus.47134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Acute neurological manifestations in patients with Behcet's syndrome are rare yet may lead to devastating outcomes. Distinguishing primary neurological deficits from spontaneous hemorrhagic insults is of particular importance for the prognosis of patients with Behcet's syndrome. Here, we investigate the clinical characteristics, management, and outcomes of nontraumatic hemorrhagic injury in patients with Bechet's syndrome. Following the case presentation, a systematic review of the literature identified cases of spontaneous hemorrhage among patients with Behcet's syndrome. Variables of interest were collected from each article to characterize patient demographics, clinical manifestations, management, and reported outcomes. Additionally, a rare case of nontraumatic intramedullary spinal bleeding in a young male with Behcet's syndrome is presented. Including our case, we analyzed 12 cases of spontaneous bleeding associated with Behcet's syndrome in 12 articles. Patient age ranged from 16 to 71 (median = 36), with a male predominance (n = 11, 91.7%). Involvement of cardiothoracic structures (n = 3, 25%), pulmonary (n = 4, 33.3%), and gastrointestinal or genitourinary vasculature (n = 3, 25%) was most common, followed by extracranial (n = 2, 16.7%) and central nervous system vasculature (n = 1, 8.3%). Clinical presentation varied depending on which specific systems or anatomical structures were involved. Anticoagulation or antiplatelet therapy was mentioned in three cases (27.3%). Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) were noted to be elevated in six cases (54.5%). Most cases were managed surgically (n = 8, 66.7%); four cases were managed conservatively (33.3%). In our case, the patient's intramedullary bleed was allowed to dissolve without further manipulation. Of the reported outcomes, major recovery was achieved in 10 patients (83.3%), and two patients died from aneurysm or pseudoaneurysm rupture (16.7%). New-onset neurological findings in patients with Behcet's syndrome should raise suspicion for possible spontaneous hemorrhage. Our case presents the first reported instance of an abrupt onset of neurological injury secondary to intramedullary spinal cord bleed in Behcet's syndrome. A systematic review of the literature demonstrates no difference in mortality for patients managed conservatively compared to those who undergo surgical treatment.
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Affiliation(s)
- Ankita Das
- Neurosurgery, New York Medical College, Valhalla, USA
| | - Sima Vazquez
- Neurosurgery, New York Medical College, Valhalla, USA
| | | | | | | | - John K Houten
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, USA
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7
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Ahmed E, Saleh-Anaraki K, Onyegbule C, AlAfun M, Ammar HM. A Zebra Diagnosis: A Case of Spontaneous Hematomyelia Associated With COVID-19. Cureus 2023; 15:e40452. [PMID: 37456427 PMCID: PMC10349385 DOI: 10.7759/cureus.40452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/18/2023] Open
Abstract
Spontaneous non-traumatic spinal hematomyelia, characterized by intramedullary spinal hematoma, is a rare neurological emergency. Bleeding arteriovenous malformation, coagulopathies, and neoplasms are reported causes of this rare diagnosis. The authors present a case of a previously healthy man who presented with acute paraplegia and was found to have a spontaneous hematomyelia in association with covid infection. He underwent laminectomy and hematoma evacuation but did not recover any neurological function.
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Affiliation(s)
- Elham Ahmed
- Internal Medicine, University of Maryland Capital Region Medical Center, Largo, USA
| | - Kimia Saleh-Anaraki
- Internal Medicine, University of Maryland Capital Region Medical Center, Largo, USA
| | - Chima Onyegbule
- Internal Medicine, University of Maryland Capital Region Medical Center, Largo, USA
| | - Mamoon AlAfun
- Internal Medicine, University of Maryland Capital Region Medical Center, Largo, USA
| | - Hussam M Ammar
- Internal Medicine, University of Maryland Capital Region Medical Center, Largo, USA
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8
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Hakimi R. Imaging of Central Nervous System Hemorrhage. Continuum (Minneap Minn) 2023; 29:73-103. [PMID: 36795874 DOI: 10.1212/con.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVE This article aims to familiarize the reader with the various types of nontraumatic central nervous system (CNS) hemorrhage and the various neuroimaging modalities used to help diagnose and manage them. LATEST DEVELOPMENTS According to the 2019 Global Burden of Diseases, Injuries, and Risk Factors Study, intraparenchymal hemorrhage accounts for 28% of the global stroke burden. In the United States, hemorrhagic stroke makes up 13% of all strokes. The incidence of intraparenchymal hemorrhage increases substantially with age; thus, despite improvements in blood pressure control through various public health measures, the incidence is not decreasing as the population ages. In fact, in the most recent longitudinal study of aging, autopsy findings showed intraparenchymal hemorrhage and cerebral amyloid angiopathy in 30% to 35% of patients. ESSENTIAL POINTS Rapid identification of CNS hemorrhage, which includes intraparenchymal hemorrhage, intraventricular hemorrhage, and subarachnoid hemorrhage, requires either head CT or brain MRI. Once hemorrhage is identified on the screening neuroimaging study, the pattern of blood in conjunction with the history and physical examination can guide subsequent neuroimaging, laboratory, and ancillary tests as part of the etiologic assessment. After determination of the cause, the chief aims of the treatment regimen are reducing hemorrhage expansion and preventing subsequent complications such as cytotoxic cerebral edema, brain compression, and obstructive hydrocephalus. In addition, nontraumatic spinal cord hemorrhage will also be briefly discussed.
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9
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Malomo T, Allard Brown A, Bale K, Yung A, Kozlowski P, Heran M, Streijger F, Kwon BK. Quantifying Intraparenchymal Hemorrhage after Traumatic Spinal Cord Injury: A Review of Methodology. J Neurotrauma 2022; 39:1603-1635. [PMID: 35538847 DOI: 10.1089/neu.2021.0317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Intraparenchymal hemorrhage (IPH) after a traumatic injury has been associated with poor neurological outcomes. Although IPH may result from the initial mechanical trauma, the blood and its breakdown products have potentially deleterious effects. Further, the degree of IPH has been correlated with injury severity and the extent of subsequent recovery. Therefore, accurate evaluation and quantification of IPH following traumatic spinal cord injury (SCI) is important to define treatments' effects on IPH progression and secondary neuronal injury. Imaging modalities, such as magnetic resonance imaging (MRI) and ultrasound (US), have been explored by researchers for the detection and quantification of IPH following SCI. Both quantitative and semiquantitative MRI and US measurements have been applied to objectively assess IPH following SCI, but the optimal methods for doing so are not well established. Studies in animal SCI models (rodent and porcine) have explored US and histological techniques in evaluating SCI and have demonstrated the potential to detect and quantify IPH. Newer techniques using machine learning algorithms (such as convolutional neural networks [CNN]) have also been studied to calculate IPH volume and have yielded promising results. Despite long-standing recognition of the potential pathological significance of IPH within the spinal cord, quantifying IPH with MRI or US is a relatively new area of research. Further studies are warranted to investigate their potential use. Here, we review the different and emerging quantitative MRI, US, and histological approaches used to detect and quantify IPH following SCI.
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Affiliation(s)
- Toluyemi Malomo
- International Collaboration on Repair Discoveries, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Aysha Allard Brown
- International Collaboration on Repair Discoveries, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kirsten Bale
- International Collaboration on Repair Discoveries, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,UBC MRI Research Center, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrew Yung
- International Collaboration on Repair Discoveries, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,UBC MRI Research Center, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Piotr Kozlowski
- International Collaboration on Repair Discoveries, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,UBC MRI Research Center, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Manraj Heran
- Department of Radiology, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Femke Streijger
- International Collaboration on Repair Discoveries, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian K Kwon
- International Collaboration on Repair Discoveries, Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver Spine Surgery Institute, Department of Orthopaedics, and Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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10
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Rosas Almanza J, Stehlik KE, Page JJ, Xiong SH, Tabor EG, Aperi B, Patel K, Kodali R, Kurpad S, Budde MD, Tarima S, Swartz K, Kroner A. IL-12p40 promotes secondary damage and functional impairment after spinal cord contusional injury. J Neurosci Res 2022; 100:2213-2231. [PMID: 36089917 DOI: 10.1002/jnr.25122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/23/2022] [Accepted: 08/29/2022] [Indexed: 01/07/2023]
Abstract
Secondary damage obstructs functional recovery for individuals who have sustained a spinal cord injury (SCI). Two processes significantly contributing to tissue damage after trauma are spinal cord hemorrhage and inflammation: more specifically, the recruitment and activation of immune cells, frequently driven by pro-inflammatory factors. Cytokines are inflammatory mediators capable of modulating the immune response. While cytokines are necessary to elicit inflammation for proper healing, excessive inflammation can result in destructive processes. The pro-inflammatory cytokines IL-12 and IL-23 are pathogenic in multiple autoimmune diseases. The cytokine subunit IL-12p40 is necessary to form bioactive IL-12 and IL-23. In this study, we examined the relationship between spinal cord hemorrhage and IL-12-related factors, as well as the impact of IL-12p40 (IL-12/IL-23) on secondary damage and functional recovery after SCI. Using in vivo magnetic resonance imaging and protein tissue analyses, we demonstrated a positive correlation between IL-12 and tissue hemorrhage. Receptor and ligand subunits of IL-12 were significantly upregulated after injury and colocalized with astrocytes, demonstrating a myriad of opportunities for IL-12 to induce an inflammatory response. IL-12p40-/- mice demonstrated significantly improved functional recovery and reduced lesion sizes compared to wild-type mice. Targeted gene array analysis in wild-type and IL-12p40-/- female mice after SCI revealed an upregulation of genes associated with worsened recovery after SCI. Taken together, our data reveal a pathogenic role of IL-12p40 in the secondary damage after SCI, hindering functional recovery. IL-12p40 (IL-12/IL-23) is thus an enticing neuroinflammatory target for further study as a potential therapeutic target to benefit recovery in acute SCI.
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Affiliation(s)
- Jose Rosas Almanza
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Kyle E Stehlik
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Justin J Page
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Shuana H Xiong
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Emma G Tabor
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Brandy Aperi
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Kishan Patel
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Rajiv Kodali
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Shekar Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Matthew D Budde
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Sergey Tarima
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Karin Swartz
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Antje Kroner
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
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11
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Hiett A, Gaughan Z, Polston K, Clark M. Ruptured aneurysm of the artery of Adamkiewicz as a rare cause of spinal cord injury. BMJ Case Rep 2022; 15:e250840. [PMID: 36007976 PMCID: PMC9422830 DOI: 10.1136/bcr-2022-250840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This case report describes a patient who presented with low back pain, headache and urinary retention. He developed altered mental status with right lower extremity hemiparesis. He was subsequently found to have subarachnoid haemorrhage and was ultimately diagnosed with a ruptured aneurysm of the artery of Adamkiewicz. At 11-week follow-up, he had made a significant recovery and was functioning at a modified independent level. This case report explores previous cases of ruptured artery of Adamkiewicz aneurysms as a rare cause of spinal cord injury, and discusses management and recovery for these injuries.
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Affiliation(s)
- Andrew Hiett
- Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Zachary Gaughan
- Department of Radiology, University of Missouri, Kansas City, Missouri, USA
| | - Keith Polston
- Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Megan Clark
- Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, Kansas, USA
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12
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Boukobza M, Laissy JP. Left hemi-conus medullaris hematomyelia complicating oral anticoagulant therapy. Rev Neurol (Paris) 2022; 178:629-631. [DOI: 10.1016/j.neurol.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/31/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
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13
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Xiao Y, Yang J, Xia J, Liu Y, Huang Q, Feng J. Spinal subarachnoid haemorrhage secondary to spinal rheumatoid vasculitis: a case report. BMC Neurol 2021; 21:465. [PMID: 34847873 PMCID: PMC8630905 DOI: 10.1186/s12883-021-02497-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Spinal subarachnoid haemorrhage is extremely rare in cases of subarachnoid haemorrhage and possesses servere characteristics. Additionally, spinal rheumatoid vasculitis is rare for spinal subarachnoid haemorrhage. The pathogenesis is unknown. Case presentation A 52-year-old woman with a 10-year history of seropositive rheumatoid arthritis was managed with leflunomide and celecoxib, and stable low disease activity was achieved. The patient had also been diagnosed with spinal subarachnoid haemorrhage secondary to isolated spinal rheumatoid vasculitis and obtained good therapeutic effects. Conclusion This is the first case to describe spinal subarachnoid haemorrhage secondary to isolated spinal vasculitis in a patient with rheumatoid arthritis, which provides more proof of anomalous neovascularization in the central nervous system in rheumatoid arthritis.
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Affiliation(s)
- Yeqing Xiao
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, 410008, Hunan Province, China
| | - Jie Yang
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, 410008, Hunan Province, China
| | - Jian Xia
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, 410008, Hunan Province, China
| | - Yunhai Liu
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, 410008, Hunan Province, China
| | - Qing Huang
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, 410008, Hunan Province, China
| | - Jie Feng
- Department of Neurology, Xiangya Hospital, Central South University, Xiangya Road 87, Changsha, 410008, Hunan Province, China.
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Spinal vascular lesions: anatomy, imaging techniques and treatment. Eur J Radiol Open 2021; 8:100369. [PMID: 34307789 PMCID: PMC8283341 DOI: 10.1016/j.ejro.2021.100369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/23/2021] [Accepted: 07/04/2021] [Indexed: 11/23/2022] Open
Abstract
Vascular myelopathies include different aetiology and mechanism of damage. The level of the lesion and the localization within the SC correlates with the clinical symptoms. CT, MRI and angiography are essential for diagnosis and treatment playing a complementary role. MRI is the gold standard for the evaluation of spinal cord lesions. Spinal angiography is the gold standard for evaluation of spinal cord vasculature and vascular malformations.
Background Vascular lesions of the spinal cord are rare but potentially devastating conditions whose accurate recognition critically determines the clinical outcome. Several conditions lead to myelopathy due to either arterial ischemia, venous congestion or bleeding within the cord. The clinical presentation varies, according with the different aetiology and mechanism of damage. Purpose The aim is to provide a comprehensive review on the radiological features of the most common vascular myelopathies, passing through the knowledge of the vascular spinal anatomy and the clinical aspects of the different aetiologies, which is crucial to promptly address the diagnosis and the radiological assessment.
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Abstract
Vascular disorders of the spinal cord are uncommon yet under-recognized causes of myelopathy. Etiologies can be predominantly categorized into clinical and radiographic presentations of arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage. While vascular myelopathies often produce significant morbidity, recent advances in the understanding and recognition of these disorders should continue to expedite diagnosis and proper management, and ideally improve patient outcomes. This article comprehensively reviews relevant spinal cord vascular anatomy, clinical features, radiographic findings, treatment, and prognosis of vascular disorders of the spinal cord.
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Condette-Auliac S, Gratieux J, Boulin A, Di Maria F, Consoli A, Coskun O, Smajda S, Rodesch G. Imaging of vascular diseases of the spinal cord. Rev Neurol (Paris) 2021; 177:477-489. [PMID: 33902944 DOI: 10.1016/j.neurol.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/13/2021] [Indexed: 11/15/2022]
Affiliation(s)
- S Condette-Auliac
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch, Suresnes, France.
| | - J Gratieux
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch, Suresnes, France
| | - A Boulin
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch, Suresnes, France
| | - F Di Maria
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch, Suresnes, France
| | - A Consoli
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch, Suresnes, France
| | - O Coskun
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch, Suresnes, France
| | - S Smajda
- Department of interventional Neuroradiology, Fondation Rotschild, Paris, France
| | - G Rodesch
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch, Suresnes, France
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Limaye K, Kandemirli S, Dlouhy K. Spinal subarachnoid hemorrhage secondary to ruptured artery of Adamkiewicz aneurysm: Is conservative management the first best step? Clin Neurol Neurosurg 2021; 205:106647. [PMID: 33932775 DOI: 10.1016/j.clineuro.2021.106647] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/17/2021] [Accepted: 04/09/2021] [Indexed: 10/21/2022]
Abstract
A 43-year-old woman presented to the hospital with severe low back pain and paresthesias in the bilateral lower extremities. MRI of the spine revealed spinal subarachnoid and subdural hemorrhage extending from T11 to L5-S1. A diagnostic spinal angiogram demonstrated a dissecting, partially thrombosed aneurysm of the artery of Adamkiewicz.At four weeks from the sentinel event, her symptoms had completely resolved with resolution on imaging.Isolated artery of Adamkiewicz aneurysms, which are most often dissecting, fusiform aneurysms are extremely rare and management controversial.
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Affiliation(s)
- Kaustubh Limaye
- Division of Cerebrovascular Diseases, Department of Neurology, University of Iowa, Carver College of Medicine, The University of Iowa, USA; Division of Neuro-Endovascular Surgery, Department of Radiology, University of Iowa, Carver College of Medicine, The University of Iowa, USA.
| | - Sedat Kandemirli
- Division of Neuro-Endovascular Surgery, Department of Radiology, University of Iowa, Carver College of Medicine, The University of Iowa, USA
| | - Kathleen Dlouhy
- Department of Neurosurgery, University of Iowa, Carver College of Medicine, The University of Iowa, USA
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Abstract
PURPOSE OF REVIEW Neurologists should be able to identify clinical and neuroimaging features that distinguish vascular disorders from other causes of myelopathy. RECENT FINDINGS Although certain clinical features suggest a vascular etiology in acute and chronic myelopathy settings, accurate MRI interpretation within the clinical context is key. Recent studies have shown vascular myelopathies are frequently misdiagnosed as transverse myelitis, and recognition of this diagnostic pitfall is important. Many different vascular mechanisms can cause myelopathy; this article provides a comprehensive review that simplifies disease categories into arterial ischemia, venous congestion/ischemia, hematomyelia, and extraparenchymal hemorrhage. SUMMARY It is important to recognize and manage vascular disorders of the spinal cord as significant causes of acute, subacute, and progressive myelopathy.
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Cioffi GM, Regoli F, Conte G, Auricchio A. Acute fluctuating neurological deficits after pulmonary vein isolation: unmasking a rare complication due to spontaneous spinal subdural bleeding: a case report. Eur Heart J Case Rep 2019; 3:ytz109. [PMID: 31660485 PMCID: PMC6764566 DOI: 10.1093/ehjcr/ytz109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/04/2019] [Accepted: 06/17/2019] [Indexed: 11/29/2022]
Abstract
Background Pulmonary vein isolation (PVI) is becoming the therapy of choice for symptomatic paroxysmal drug-refractory atrial fibrillation (AF). The most frequently reported complications are vascular complications (1.4%). Bleeding complications of the central nervous system have rarely been described. We report a case of spontaneous spinal bleed after PVI. Case summary A 68-year-old woman with a 2-year history of highly symptomatic paroxysmal AF (EHRA 3) was referred for a PVI redo procedure. A high-density mapping showed pulmonary vein reconnection of all pulmonary veins successfully isolated by radiofrequency ablation. During the entire procedure, the patient had sinus rhythm with an ACT around 300 s. No intraprocedural and peri-procedural complications occurred. Four hours after haemostasis, the anticoagulation clotting time (ACT) was 110 s and rivaroxaban (20 mg) was reinitiated. In the following hours, the patient developed fluctuating neurological lower limb symptoms. A lumbar magnetic resonance imaging showed a subdural spinal haematic collection with an associated epidural component from L3 to S2 exerting compression over the dural sheath. A conservative treatment approach was adopted with progressive recovery of sensorial and motor deficits. After 5 months, the patient still presented residual lower limb motor deficits necessitating the support of a walking stick. Discussion We describe the first case of a spontaneous spinal bleeding following PVI. Given the gradual diffusion of PVI to treat AF in more clinically complex patients with a larger range of comorbidities, particular consideration should be given to seek predisposing bleeding factors in order to assess the risk for neurological complications.
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Affiliation(s)
- Giacomo Maria Cioffi
- Department of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland
| | - François Regoli
- Department of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland
| | - Giulio Conte
- Department of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland
| | - Angelo Auricchio
- Department of Cardiology, Fondazione Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland
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Smith G, Hoh BL, Albayram MS. Anterior spinal artery aneurysm presenting with spinal subarachnoid hemorrhage in a case of polyarteritis nodosa. Clin Imaging 2019; 56:108-113. [DOI: 10.1016/j.clinimag.2019.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/09/2019] [Accepted: 04/16/2019] [Indexed: 12/21/2022]
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Kilic M, Kilic B, Aydin MD, Yilmaz I, Yilmaz A, Yilmaz F, Kurt A, Nuri Kocak M. The casual association of cervical spinal cord ischemia and axonal degeneration in second motor neuron following subarachnoid hemorrhage: Experimental study. J Clin Neurosci 2019; 66:235-238. [PMID: 31153749 DOI: 10.1016/j.jocn.2019.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
AIM Muscle abnormalities after spinal cord ischemia caused by subarachnoid hemorrhage (SAH) have not been explored for degenerative variations in the soma of second motor neurons of the spinal cord gray matter. This study aimed to investigate histopathological alterations in the gray matter and the role of peripheral nerves in SAH. MATERIAL AND METHODS Twenty-two rabbits were allocated in the control (Group I, n = 5), SHAM (Group II, n = 5), and research (Group III, n = 12) groups. Muscle weakness of the upper extremities innervated by radial nerves was evaluated at the initial day, and outcomes were recorded as control data. Re-measurements were done after injecting 0.5 ml of SF for SHAM and autolog artery blood inside craniocervical subarachnoid space for the study group. After 3 weeks, radial nerve roots, their ganglia, and segments of the spinal cord around C5-6 root entry zones were extracted bilaterally. Degenerated second motor neuron somas and the degenerated radial nerve motor axons at the intervertebral foramen were assessed. RESULTS The average degenerated soma intensity/mm3 at the C5-6 levels in the spinal cord was 2 ± 1/mm3, 13 ± 4/mm3, and 56 ± 10/mm3 for Groups I, II, and Group III. The average degenerated axon intensity of radial nerves was 3 ± 1/mm2, 34 ± 9/mm2, and 234 ± 78/mm2 for Groups I, II, and III. CONCLUSION Gray matter ischemia in the spinal cord may lead to axonal deterioration on equal levels at the peripheral nerves with advanced SAH. Detected or undetected spinal SAH should be considered an important factor on the etiology of second motor neuron diseases.
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Affiliation(s)
- Mustafa Kilic
- Department of Neurosurgery, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Betul Kilic
- Department of Pediatric Neurology, Kocaeli Derince Education and Research Hospital, Kocaeli, Turkey
| | - Mehmet Dumlu Aydin
- Department of Neurosurgery, Medical Faculty of Ataturk University, Erzurum, Turkey.
| | - Ilhan Yilmaz
- Department of Neurosurgery, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Adem Yilmaz
- Department of Neurosurgery, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Figen Yilmaz
- Department of Physical Therapy and Rehabilitation, Sisli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Ali Kurt
- Department of Pathology, Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Mehmet Nuri Kocak
- Department of Neurosurgery, Medical Faculty of Ataturk University, Erzurum, Turkey
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Wada T, Kitaguchi H, Shindo K. [Primary angiitis of the central nervous system with cerebral infarction and spinal hemorrhage]. Rinsho Shinkeigaku 2019; 59:268-273. [PMID: 31061305 DOI: 10.5692/clinicalneurol.cn-001288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A 61-year-old woman presented with acute intense lower back pain and weakness in her left leg. She also presented with throbbing headache on the same day. On admission, muscle weakness in her left leg, lower left quadrantanopia and left lower extremity deep sensory disturbance were observed. Laboratory data showed no coagulopathy and autoimmune antibody was negative. Cerebrospinal fluid examination showed bloody and inflammatory findings. Brain MRI revealed cerebral infarction with multiple intracranial arterial stenosis and convexal subarachnoid hemorrhage. Spinal MRI revealed spinal hemorrhage in the cervical, thoracic, and part of the lumbar spine. Because these lesions occurred simultaneously, we made a diagnosis of vasculitis. After high dose corticosteroids therapy was undertaken, the multiple arterial stenosis improved. Primary angiitis of the central nervous system is sometimes difficult to distinguish from reversible cerebral vasoconstriction syndrome in its initial stage; although symptoms, examination findings and treatment differ in both.
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Case report: difficulty in diagnosis of delayed spinal epidural hematoma in puerperal women after combined spinal epidural anaesthesia. BMC Anesthesiol 2019; 19:54. [PMID: 30975081 PMCID: PMC6460545 DOI: 10.1186/s12871-019-0721-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 03/28/2019] [Indexed: 11/18/2022] Open
Abstract
Background Spinal epidural hematoma is a rare but serious complication of epidural anaesthesia and neurological impairment. Epidural hematoma usually becomes evident within a few hours of the procedure. Delayed clinical presentation of spinal epidural hematoma is even rarer and insidious. Case presentation We reported a case of a 44-year-old woman who underwent a caesarean section for a twin pregnancy during which a delayed dorsal spinal epidural hematoma occurred. Symptoms were reported 5 days after surgery and 72 h after removal of the epidural catheter. An MRI scan showed a dorsal epidural hematoma. The patient was moved to the Neurosurgical Department and underwent decompression surgery. Conclusion The possibility of the delayed onset of a spinal epidural hematoma in a pregnant woman who undergoes epidural anaesthesia in labour must always be taken into consideration. In order to achieve the best clinical result, we stress the importance of a timely diagnosis and prompt surgical treatment.
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